Rural hospitals experience unique difficulties with effective and accurate application of evidence-based patient safety solutions.1-4 Patient safety concerns arising from the identification and management of acute time-sensitive critical conditions in rural Emergency Departments (ED) are especially concerning given the high probability of harm or even death when errors occur. Well-established, evidence-based guidelines for identification and safe management of acute, time-sensitive critical conditions in the ED, such as acute sepsis, have been developed in large academic centers, yet there remain significant disparities in effective and accurate implementation and application of these guidelines and outcomes in rural EDs.2,3,5,6 Telemedicine provides a unique approach for delivering consistent, safe care to patients across all settings: from large academic to small rura hospitals.7,8 Use of telemedicine to improve patient safety in rural EDs provides unique opportunities, but also significant operational challenges, as these EDs experience continuous change with respect to patient volume, presentations of clinical conditions, as well as clinician expertise, experience, and staffing. In situ simulation, simulation that takes place in the live, operational, clinical setting with clinicians performing their real roles, provides the ability to rain and evaluate the integration of new technology, such as telemedicine, along with care guidelines, such as the acute sepsis bundle, into clinical practice and workflow. The goal of this project will be to evaluate if in situ simulation improves adoption and use of telemedicine to support implementation of the Acute Sepsis Bundle, to improve the safe delivery of care in rural EDs. We will conduct a prospective delayed intervention study to evaluate the impact of the optimized Telemedicine Acute Sepsis Bundle in two rural EDs within the Order of St. Francis (OSF) Healthcare System. The large academic center within OSF Healthcare is currently engaged in a process improvement effort to improve with safety of sepsis care, has developed and piloted an Acute Sepsis Bundle, and is committed to using telemedicine to improve dissemination in the OSF-affiliated rural hospital EDs. This project will develop, pilot, and finalize an in situ simulation training program to first tailor an optimized Telemedicine Acute Sepsis Bundle for each rural ED, and then train rural ED clinicians to integrate this new technology and care process into their workflow. We will evaluate the impact of in situ simulation on both (1) process measures: telemedicine and Acute Sepsis Bundle delivery, and (2) clinical outcomes: sepsis mortality and intensive care unit length of stay. Results will be disseminated in an In situ Simulation for Patient Safety Toolkit. This project will produce results that can be easily translated to the implementation of other new technologies and care processes targeting acute, time- sensitive critical conditions, such as stroke, acute myocardial infarction, acute decompensated heart failure, pediatric critical care, and trauma, to improve patient safety in the country's many rural EDs.